The CMG Voice

As you might imagine, unnecessary hospitalizations can be costly. And when hundreds of patients have to go to the hospital for reasons that would have been avoided with proper preventative care, the cost is greatly multiplied.

A new study recently came out from Washington’s Office of Financial Management, and looked at this issue in our state. It found that millions of dollars are being wasted in hospitalizations that should have been avoided – and the worst place for such events is in and around the Tacoma area.

While the statewide average for preventable hospital stays per 100,000 people was 645, the legislative district encompassing South Tacoma, Lakewood and Spanaway was more than double that, with 1,299 such hospitalizations. A close second was north Tacoma, with 1,041 hospitalizations per 100,000 people.

On the opposite end of the spectrum, the 46th legislative District (mostly Seattle) and the 41st Legislative District (Bellevue and Mercer Island) both had hospitalization rates better than state average in all 11 conditions the study examined.

As noted above, the cost of these preventable hospitalizations is huge – around $487,000,000 per year. Unfortunately, funding for preventative care through community health programs was not included in this year’s state budget. Without greater spending to address the underlying causes of preventative illnesses, it’s hard to make a reasonable claim that the situation will get any better.

Swedish Hospital has largely stopped the practice of overlapping surgeries in response to the concerns made by the public.

As you may recall, this largely came to light after the Seattle Times ran a series of investigative stories about the practice at Swedish in February. You can read earlier blog posts on the topic of overlapping surgeries here and here. Since that time, Swedish has undergone management changes, and doctors and other health care providers have left.

Swedish’s new CEO, Dr. Guy Hudson, described the new policy to a reporter for the Seattle Times on Monday, August 7. Now, surgeons must be present for the “substantial majority” of each surgical procedure. However, they are not required to be present during parts of the beginning or end of each surgery. The Times article doesn’t otherwise spell out what “substantial majority” means, although a fair reading is that it is more than 50%, and certainly more than the “critical portions” of surgical cases that surgeons were required to be at prior to the change.

Additionally, staff will document the times surgeons enter and exit the operating room. One would hope this change ensures compliance with the “substantial majority” requirement for presence in the surgery.

It is unclear whether the other Seattle hospitals who allow overlapping surgeries – Virginia Mason and University of Washington – will follow Swedish’s lead. With an informed patient population, one would think that Swedish’s push to increase the perception of public safety if not actual safety (Dr. Hudson noted that overlapping surgery is in fact safe) would be good for business, particularly if their competitors fail to follow suit. Alternatively, Swedish may make less money because it is not able to do as many surgeries as before.

The Doctors Company promotes itself as the largest physician-owned medical malpractice insurer in the country. Recently, it analyzed nearly 2000 claims from 2007-2014, looking for why patients brought lawsuits against their orthopedic surgeon.

A handy chart goes into greater detail, but results of the study were divided into “most common patient allegations” and “factors contributing to patient injury”.

The most common patient allegation is that the surgeon didn’t perform the surgery correctly (46%). Of course, not all of these allegations resulted from a surgeon committing malpractice; often there are bad outcomes from surgery (or to use the insurer’s language, “the outcome … differed from the patient’s expectations”).

The two biggest factors this insurer found contributing to patient injury were “technical performance” (35%) and “patient factors” (29%). Other categories included “selection and management of therapy”, “communication between patient/family and provider”, and “Patient assessment issues” (all 12%).

The most striking to me is “Patient factors” – the analysis found that the second leading cause of patient injury was the patients themselves – including seeking other providers due to dissatisfaction with care, not following the post operative treatment plan or not coming to follow up appointments.

Certainly, I can understand a patient’s responsibility as a team member in any orthopedic surgery. This obviously includes adhering to rehabilitation plans, coming in for follow up appointments, and the like. What I can’t quite figure out is why a patient should be faulted for seeking out another provider (likely another orthopedic surgeon) when they are dissatisfied with their current one. This is consistent with the focus group work I have done, in which participants regularly ask if the patient sought a second opinion. If the patient did not, he or she was faulted.

Finally, the handy chart includes “Risk Mitigation Strategies” on the bottom; easy to follow instructions for its members on how to attempt to avoid being sued.

For patients, it may be an interesting read, particularly those entertaining the possibility of orthopedic surgery in the near future.

The results of a recent study suggest that where you choose to deliver your baby may affect your chances of having a c-section.

An article describing the results of the study came out recently in the publication Obstetrics & Gynecology. The researchers interviewed health care providers from labor and delivery (L&D) units at 53 hospitals across the United States.

The researchers found that three factors may influence whether low risk delivering mothers end up having c-sections: 1) the management of L&D unit culture; 2) patient flow; and 3) nursing.

One suggestion from the article is for expecting mothers to ask a prospective hospital what their c-section rate is for low-risk women. The Department of health and Human Resources has said in the recent past that a rate under 24% is considered reasonable.

A recent 2016 survey in the Seattle found that the rate ranged from 18.9% at Highline Medical Center to 32.4% at UW Medical Center.

From time to time I either represent clients or speak on the phone with potential clients who tell me that they have recorded their doctor visit.

Sometimes the patient is open and honest with their doctor about the recording, and the doctor consents to the recording. As many of us can understand, it can be difficult to remember everything a doctor tells us in a visit, particularly if we are facing a serious illness that may have an emotional component to it. In such circumstances, a recording is a great way to be an active listener in the visit, knowing that you don’t need to furiously write notes of what is being said.

Other times, the intent of the patient is a little less benign; he or she does not get permission from the doctor, and secretly records the conversation. Unfortunately, often the motive behind this can be traced back to a feeling of lack of trust between patient and doctor.

Apparently these are not isolated, uncommon situations. A recent JAMA article summarized research that indicates that as many as 1 in 10 patients record their visits.

In 39 states and the District of Columbia, this covert recording may not improve the relationship between patient and doctor, but it is not illegal. These states are one-party consent states, meaning the patient can record the conversation with his or her doctor without the doctor’s consent.

However, Washington and 10 other states follow the two party consent rule – you need permission from the doctor before recording the visit. See RCW 9.73.030. Essentially what this means is, in situations that are “private”, such as a doctor’s exam room with the door closed, you need to get consent from the doctor or you are breaking the law.

So, in Washington, if you are thinking about recording your next doctor’s visit, ask for permission!